I was amazed and pleased to be asked to present a BBC2 Horizon documentary on OCD, entitled “A monster in my mind”. It was a huge opportunity for me to learn about this disorder and find out where the latest research had arrived at. The inevitable question was why would I do this and what made me say yes to the film project. For once, this is easy for me answer.
When I was a young student in Saarbrücken, Germany in the early 1960s, I was quite undecided what I should study. I went to many different lectures all at the same time, as I had no idea what subject to specialise in. One day my decision was suddenly made for me. This was during a Psychiatry lecture, which psychologists as well as medical students could attend. The Professor had brought along one of his patients who suffered from OCD. The patient impressed me hugely. He spoke in a strikingly rational way about how he was obsessed by an absurdly irrational fear. He was convinced that, if he did not rid himself of germs, there was a real chance that he could infect members of his family through wounds they might have accidentally required. He could not bear the thought that it would be entirely his fault, if they then died of blood poisoning. It was a monstrous fear that haunted him all his waking hours, and that no amount of washing could rid him of.
Like most people I had thought that being obsessive and compulsive was merely a quirky personality characteristic, and quite a common one. I imagined that I too was a bit obsessive. I can remember that, as a child I sometimes had the urge to touch every fence post, and I am still strongly drawn to straightening picture frames when they hang askew. But that was a long way from the case that I witnessed. It made me realise that OCD is a harrowing mental illness. But this was also very different from what I had imagined mental illness to be. I had observed some schizophrenic patients who were utterly convinced that their irrational thoughts were nothing but the bare truth.
The patient’s story was gripping. The monster had only grown stronger over the years. He washed his hands whenever there was even the slightest possibility of germs settling on them. This was nearly all the time. The cleaning procedures he imposed on himself were excessive to the point of harm, and they made his life a misery. He spent hours at the washbasin, using not only soap, but also disinfectant and even bleach. How did this square up with the incredibly rational account of himself that the patient was able to give? He knew the cleaning procedures he imposed on himself were hopelessly ineffective and only ever gave him a few moments’ relief. He knew this, and yet he could not stop them.
From then on I knew what I wanted to do. I wanted to be a researcher and find out what makes the mind behave in such a strangely contradictory way. How could your own mind keep you in thrall of some unimaginable fear when you knew that the fear was irrational? This was like creating your own nightmare and never being able to escape from it. I started to read avidly about mental illness and found that the then available methods of treatment, ranging from lobotomy, electroshock, psychoactive drugs to psychoanalysis, were spectacularly unsuccessful.
But then, in the psychology department I heard about a new way of treating mental illness that was being developed in London’s Maudsley Hospital. I knew I had to go there and learn more about it. The revolutionary new way was called Behaviour Therapy, and OCD, together with other anxiety disorders, was a showcase for its success. By good fortune I was accepted on a course in what was then called ‘Abnormal Psychology’. I had already decided to do a PhD on OCD, but fate intervened. During my rotation on the course I met children with autism. This diverted my interest from OCD. But that is another story. Actually, autism too is often associated with obsessions and compulsions, but these aspects are not central to the condition.
From time to time I have wondered wistfully what progress had been made in our understanding of OCD. This was why I was extremely excited to be asked to present this documentary. It gave me a chance to catch up on new developments and it immediately rekindled my earliest interests in the mind and brain.
One particularly gratifying experience during filming was that I was able to visit Isaac Marks, who had been one of the pioneers of Behaviour Therapy at the Maudsley when I was a student. It was fascinating to hear him reminisce about his first attempts to apply the insights he had gained from an animal learning experiment he had watched in the US.
Remarkably, later on during the filming, I saw a version of this same experiment being carried out with humans in the brain scanner at Cambridge’s Addenbrookes’ Hospital. Here it is: Patients with OCD learned to avoid a mild shock by pressing a pedal as well as anybody else, but unlike other people, after the electrode that administered the shock was removed, they continued to press the pedal, quite unnecessarily. This is a sign of cognitive inflexibility, a cause of OCD as proposed by Cambridge neuroscientist Trevor Robbins. This and other brain imaging studies have shown that cognitive inflexibility is linked to unusually high activation of loops in and out of the basal ganglia, a region deep in the brain. One very new idea that has been buoyed by this research is that it might be possible to make this region less active by deep brain stimulation. During the filming I was able to witness such a still very experimental procedure being carried out in Amsterdam.
While updating my knowledge about OCD, I felt encouraged that the original insights that came from basic research that led first to Behaviour Therapy had stood the test of time. In the 1960s Isaac Marks showed that it was possible to get rid of his patients’ tormenting anxiety by exposing them to their fear and letting them experience it ebbing away. The patients would experience relief and also learn that the terrible consequences that they feared would not, in fact, occur. This approach is still successful, although the therapy itself has morphed into CBT. It works for the majority of cases, as I learned when I visited the Maudsley Hospital’s Child and Adolescent Department and was able to witness a CBT session in progress.
The BBC provides an excellent clickable website where some basic facts about OCD are explained. In the textbooks OCD is defined as having persistent and uncontrollable thoughts that are unwanted, and disturbing. For a diagnosis they have to significantly interfere with the ability to function in everyday life. OCD is not rare. It is estimated that between 1 and 2% of the population suffer from it. The WHO has ranked OCD in the top ten of the most disabling illnesses of any kind, in terms of lost earnings and diminished quality of life. Better than the textbooks is David Adams insightful account of his own OCD in his book “The man who couldn’t stop” which I had found illuminating. I was excited to meet him during the making of the programme and a short clip of our meeting can be seen here.
Mental illness has everything to do with the brain and we must look for the causes in the brain. During filming I was able to speak to some of the leading OCD researchers and found that they are on the way to finding the brain abnormality that can explain the cruel tricks that OCD plays on the mind. Trevor Robbins and his group in Cambridge have identified a critical neural circuit. This circuit connects two major brain regions. One is the orbitofrontal cortex, known to be concerned with achieving valued goals. The other is mid-brain region, the basal ganglia. This is known to be associated with our ability to acquire automatic habits. According to Trevor Robbins, in the case of OCD the habit system has gained dominance over the goal directed system, just as it does in drug addiction. The normal brain maintains a delicate balance between these systems, but it is clear that this balance can be disturbed and that in OCD it cannot easily be regained.
The habit system is a long evolved, and for the most part, it serves us well. It works even if the original goals are no longer relevant. There is the suggestion that automatic behaviours like washing and checking are triggered by an ancient alarm system. They serve as a precaution against invisible threats, such as contamination and predator attack. In OCD it seems that this system cannot be turned off. The potential threat is ever present. There is no way to obtain certainty that it has disappeared.
Invisible and often monstrous thoughts are the real scourge of OCD. We all have unwanted and sometimes repugnant thoughts, but they are fleeting and we can subdue them. In OCD these thoughts are obsessions, and they refuse to go away. At the same time there is an unquenchable thirst to find relief. The habit system runs in overdrive with senseless actions that are performed over and over again. These are the compulsions.
After immersing myself for some months into the world of OCD I was struck by the fact that the patients all seemed to believe that they are responsible for the consequences that might follow if they did not carry out these senseless actions. They have been called hyper-responsible. Their family, even the world at large will be catastrophically affected if they fail to carry out precautionary rituals. Why?
I couldn’t let go of this question, and here is my own take on what might be behind this excessive feeling of responsibility. We know little about how we control our own thoughts. What can be frightening is that it is possible for us to feel that we are not in control of our thoughts. Now, fortunately, most of us are under the illusion that unwanted thoughts are not caused by us, but they were caused by ‘our brain’. We can dismiss them, and then we do not feel responsible for them. People with OCD don’t have this luxury. The unwanted thoughts intrude on their full consciousness, creating the illusion that they did cause them, and therefore that they are responsible.
By the end of the filming I was convinced that OCD provides an amazing example of how our common understanding of mental illness has gradually changed over the last 50 years. Today we have much more awareness of mental illness and put less blame on those who are affected. Professional help is available. There are also excellent support networks that inform and inspire. Exciting advances are being made about the abnormal functioning of particular brain circuits, but that’s only the start. To understand how brain and mind relate to each other is a hugely complex enterprise. We have hardly embarked on it.
Image credit: http://the-dreaming-dragon.deviantart.com/art/Bleach-Ichigo-476418897